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v STATE OFCAUFORNIA ` `�i STATE WATER RESOURCES CONTROL BOARD s`y w m� ". UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A „� ry; o' °'.�rowa�• C-1/ COMPLETE THIS FORM FOR EAC CILITYISITE MARK ONLY—#I NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERM CLOSED SRE ONE ITEM O 2 INTERIM PERMIT Q d AMENDED PERMR Q e TEMPORARY SITE CLOSURE I. FACILrTYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORF N E NAME OF OPERATOR ADDRESSI OSA , /I NEAREST CROSS STREET PARCEL 0(OPTIONAL) fiFlymt CITU NAME G IV/Ip/ STATE ZIP SITE PHONE%WITH AREA CODE CA T01NWATE O CORPORATION INDIVIDUAL =PARTNERSHIP Q DISTRICTS T TAGENCY E3 CWNrY-AGENCY 0STATE-AGENCY O FEDERAL#GENCV TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR p SV IF INDIAN I ERVATION *OFTT SITE E.P.A. L D.It(apllanaQ Q 3 FARM O d PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal DAYS: NAME(LAST.FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME ILAST.FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST.FIRST) TH AREA COOP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS bmbWkm = INDIVIDUAL =1 LOCAL-AGENCY Q STATE-AGENCY O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS J WX 0m4ca% O INDIVIDUAL 0 LOCAL-AGENCY D STATE-AGENCY CORPORATION D PARTNERSHIP O COUNTYAMNCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - O Z q V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE CO P TED)—IDENTIFY THE METHOD(S) USED buoWkw I SELF-INSURED ANTEE O 3 INSURANCE O 4 SURETY BOND 5 LMEROFCREDT EXEMPTION = W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= IL= Ill. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRiNTEDB SIGNATURE) APPLICANTS TITLE DATE MONTWD*ONL LOCAL AGENCY USE ONLY COUNTY% T JURISDICTION% FACILITY a ® 0! l C) o LOCATION CODE -OPTIONAL CENSUS TR % -OP NAL SUPVISOR-DISTRICT CODE -OPTIONAL '�3 I 32- THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE IFORM A(S-91)